seizures pattern and its neuro imaging findings in...
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SEIZURES PATTERN AND ITS NEURO
IMAGING FINDINGS IN CHILDREN
Dissertation submitted to The Tamilnadu Dr. M.G.R. Medical University
in partial fulfillment of the regulations
for the award of the degree of
M.D DEGREE EXAMINATION
BRANCH VII – PAEDIATRIC MEDICINE
K.A.P. Viswanathan Government Medical College Tiruchirappalli
The Tamilnadu Dr. M.G.R. Medical University
Chennai
March – 2012
CERTIFICATE
This is to certify that the dissertation entitled “SEIZURES PATTERN
AND ITS NEURO IMAGING FINDINGS IN CHILDREN” is the bonafide
original work of Dr. P. SELVARAJ to the Faculty of pediatrics, The
Tamilnadu Dr. M.G.R. Medical university, Chennai in partial fulfillment of the
requirement for the award of M.D. Degree (Pediatrics) is a bonafide research
work carried out by him under our direct supervision and guidance.
Prof. Dr. N. UMA, MD., DCH., Prof. & Head of the Dept., Department of pediatrics
K.A.P.V. Govt. Medical College, Thiruchirappalli – 1.
Prof. Dr. A. KARTHIKEYAN, MD(FM), The Dean,
K.A.P.V. Govt. Medical College, Thiruchirappalli – 1
DECLARATION
I. Dr. P. SELVARAJ solemnly declares that the dissertation titled
“SEIZURES PATTERN AND ITS NEURO IMAGING FINDINGS IN
CHILDREN” has been prepared by me. This is submitted to The Tamilnadu
Dr. M.G.R. Medical University , Chennai in partial fulfillment of the rules and
regulations for the M.D. Degree Examination in Pediatrics (March 2012).
Place : Thiruchirappalli
Date :
Dr. P. SELVARAJ
ACKNOWLEDGEMENT
At the outset I thank the Lord, Almighty, for giving me the strength to
perform all my duties.
I would like to express my sincere gratitude to
PROF. Dr. A. KARTHIKEYAN, MD (FM)., THE DEAN, K.A.P.V.Govt.
Medical College and Annal Gandhi Memorial Government Hospital, for
allowing me to avail the facilities needed for my dissertation work.
I owe debt of gratitude to Head of Department, Department of
Pediatrics & Prof. Dr.N.UMA , MD., DCH for her invaluable guidance,
constant supervision, encouragement and support throughout the study.
I am extremely thankful to Dr.D.SAMINATHAN , MD., DCH.,
professor of Pediatrics for his compassionate guidance throughout my study.
I am extremely thankful to Dr.P.LEEMA PAULINE , MD., DM.,
Professor of Paed. Neurology, ICH & HC, Chennai, for her valuable
assistance and guidance.
I would like to thank my unit Assistant Professors of Pediatrics,
Dr.MYTHILY , MD., DCH., Dr. SIRAJUDEEN NAZEER, MD.,DCH.,
Dr. R.SURESH, MD., Dr. RAMESH, DCH. For their valuable guidance and
assistance in doing this work.
My special thanks to Prof. Dr. RAVI, MD., RD., Head Of the
Department, Radiology, for valuable guidance and assistance.
I extremely thankful to all my COLLEAGUES who helped me and
shared their knowledge about this study.
I sincerely thank all the CHILDREN and THEIR PARENTS who had
submitted themselves for this study without whom this study would not have
been possible.
ABBREVIATIONS
2D - Two dimensional
3D - Three dimensional
3D CISS - Three dimensional Constructive interference in Steady
State
ADC - Apparent diffusion Co-efficient
ADEM - Acute Demyelinating Encephalo myelitis
ALARA - As low as reasonably achievable
BFS - Benign Focal Seizure
Cho - Choline
CNS - Central Nervous System
CPS - Complex Partial Seizure
CSF - Cerebro Spinal Fluid
CT - Computed Tomography
DWI - Diffusion Weighted Imaging
EEG - Electro encephalo graphy
fMRI - Functional Magnetic resonance imaging
GTCS - Generalized Tonic – clonic Seizure
HIV - Human Immunodeficiency virus
ICH - Intra cranial hemorrhage
JME - Juvenile myoclonic Epilepsy
LGS - Lennox-Gastaut Syndrome
LRS - Localization related seizure
MEG - Magneto encephalo graphy
MFS - Multifocal seizure
MRA - Magnetic resonance Angiography
MRS - Magnetic resonance Spectroscopy
MSI - Magnetic Source Imaging
MTS - Mesial temporal Sclerosis
MERRF - Myoclonic epilepsy and Red ragged fibers
MELAS - Mitochondrial Encephalopathy with lactic acidosis
And stroke like episodes
NAA - N-Acetyl aspartate
NCC - Neurocysticercosis
NCD - Neurocutaneous Disorders
NF - Neurofibromatosis
PMFL - Progressive Multifocal encephalopathy
PNET - Primitive Neuro ectodermal tumors
PSGS - Partial seizure with Generalized Seizure
PWI - Perfusion weighted imaging
REL - Ring Enhancing Lesions
SLE - Systemic lupus Erythematosus
SPECT - Single-photon Emisson Computer Tomography
SPS - Simple Partial Seizure
SSECTL - Single Small Enhancing CT Lesions
SWS - Sturge – Weber Syndrome
TS - Tuberous Sclerosis
TB - Tuberculosis
USG - Ultra Sonography
XLALD - X-Linked Adrenoleukodystrophy
CONTENTS
S.NO CONTENTS PAGE NO
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 37
3. STUDY JUSTIFICATION 41
4. OBJECTIVE 42
5. METHODOLOGY 43
6. RESULTS AND ANALYSIS 46
7. DISCUSSION 55
8. SUMMARY AND CONCLUSION 59
9. RECOMMENDATIONS 60
10. ANNEXURES 61
BIBLIOGRAPHY
INTRODUCTION
1
INTRODUCTION
PEDIATRIC EPILEPSY
Epilepsy is defined by the occurrence of recurrent spontaneous seizures
arising from aberrant activity within the brain. Such electrical activity is the net
product of biochemical processes at the cellular level occurring in the context
of large neuronal networks, and it likely involves cortical and several key
subcortical structures.
INTERNATIONAL CLASSIFICATIONS OF SEIZURE TYPE (1)
1. FOCAL AND MULTIFOCAL SEIZURES
Simple partial seizures
With motor signs
With somatosensory or special sensory hallucinations
With autonomic symptoms
With psychic symptoms
Complex partial seizures
Simple partial followed by impairment of consciousness
With impaired consciousness at onset
Partial seizures evolving to secondary generalized seizures
Simple partial seizures evolving to generalized
Complex partial seizures evolving to generalized
Simple partial seizures evolving to complex partial seizure
2
2. GENERALIZED SEIZURES
Tonic – clonic seizures
Absence seizures
Atypical absence seizures
Clonic seizures
Tonic seizures
Atonic seizures
3. MYOCLOMUS, MYOCLONIC SEIZURES, AND INFANTILE
SPASMS
4. UNCLASSIFIABLE EPILEPTIC SEIZURES INCIDENCE (2)
The overall incidence of childhood epilepsy from birth to 16 yrs – 40
cases in 100,000 children.Incidence is
Upto1yr - 120 in 100,000
1 - 10 yrs- 40 - 50 in 100,000
10 – 20yrs. 20 in 100,000.
Syndrome dominated by generalized tonic conic or partial seizures
account for 75% of childhood epilepsy. Syndromes dominated by absence
seizures account for approximately 15%, and the secondary generalized
epilepsies account for 10%.
Focal seizures in 43%, with complex partial and partial with secondary
generalization most common. For 44%, generalized seizures were dominant,
with generalized tonic – clonic seizures most common. Overall, 45% had
localization – related epilepsy syndromes, and 48% had generalized
syndrome (3)
3
NEUROPHYSIOLOGY OF EPILEPSY
At the cellular level, the two hallmark features of epileptiform activity
are neuronal hyperexcitability and neuronal hypersynchrony. Generally, a focal
interictal discharge on an EEG cannot be seen unless a minimum of 1 to 2 cm2
of cortex exhibits increased excitability and synchrony (4).
Seizure activity as a perturbation in the normal balance between
inhibition and excitation in a localized region, in multiple areas or throughout
the whole brain(5). This imbalance is likely a combination of increased
excitation and decreased inhibition and, perhaps somewhat paradoxically, in
some instances increased inhibition impinging on individual cells.
GENETICS OF EPILEPSY
? Genes relevant to Majority of cases
Rare families: simple inheritance
multiple single gene - disorders, Genes
encode ion channel sub units.
Majority of cases: Complex
inheritance many genes, currently unknown,
Modified by environmental factors.
4
GENERAISED SEIZURES
Seizures are classified into two basic groups: Partial and Generalized.
Partial seizures arise from a localized region of the brain. Focal discharges can
spread locally through synaptic and non-synaptic mechanisms, distally to
subcortical structures, and through commissural pathways to eventually involve
the entire seizures secondarily generalize. It is called partial with secondary
generalization. Generalized seizures begin with abnormal electrical discharges
in both hemisphere and critically involve reciprocal thalamorcortical
connections. The electroencephalographic signature of a primary generalized
seizure is bilaterally synchronous spike-wave discharges seen across all scalp
electrodes. It’s called primary generalized seizures.
Primary generalized seizures accounted for 40.5%. Of the primary
generalized seizures, generalized tonic clonic are the most common, followed
by absence and myoclonic seizures (6).
GENERALIZED TONIC-CLONIC SEIZURES
The child may have a headache, insomnia, irritability, or a change in
appetite. This prodrome starts hours-days before GTCS occurs. Prodrome is not
associated with any EEG epileptiform activity.
GTCS have to distinct phases: tonic and clonic (7). Loss of consciousness
usually occurs simultaneously with the onset of a generalized stiffening of
flexor or extensor muscle the tonic phase.
5
During the tonic phase, prolonged extension of the back, neck, and all
limbs often occurs. The eyes remain open, and a cry or yell is common. The
tonic phase typically lasts 10 to 30 seconds and is followed by the clonic phase.
The clonic phase usually starts with a rapid tremor and then slows to massive
jerks of the extremities and trunk. The clonic phase typically lasts 30 to 60
seconds.
Cyanosis is common and results from the arrest of ventilation during the
tonic phase and insufficient short breaths during the following clonic phase.
Pupillary dilation, salivation, sweating, hyperthermia, and incontinence are
common.
The seizures evoked by photic stimulation usually are primary
generalized in type. Photosensitive epilepsy can be classified into two major
groups: (1) pure photosensitive epilepsy, in which clinical seizures occurs only
when the patient is exposed to the photic stimulus, and (2) photosensitive
epilepsy, in which spontaneous seizures occur in addition to those induced by
light stimulation(8).
EEG findings
The tonic phase usually begins as loss of background frequencies, with
sudden generalized suppression of the background activity, followed by
gradual buildup low voltage fast spikes, starting at 20 to 40 Hz and then
decreasing to 10 Hz, lasting up to 10 seconds, with a progressive increase in
amplitude and decrease in frequency the so called “epileptic recruiting
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rhythm.” This is followed by the clonic phase, with slow waves following the
spikes.
Initial Evaluation
Children with an unremarkable history other than for the seizures and
with normal findings on neurologic examination typically require only an EEG
and neuroimaging. Neuroimaging, Non – Emergency settings-MRI; Acute
situations-CT, mental retardation, developmental regression, or abnormalities
on neurologic examination, need for the diagnostic testing such as metabolic
screening and CSF examinations.
ABSENCE SEIZURES
Clinical Features
Absence seizures are characterized by an abrupt cessation of activity,
change in facial expression, and impairment of consciousness(9,10). Less than
10% of all seizures (11). The most common seizure type to go undetected.
Common in first 10years of life (12) and it is more common in girls (13).
Typical Absence Seizures
Sudden onset of impaired consciousness, usually associated with a blank
facial appearance without other motor or behavioral phenomena, is
characteristic. Automatisms, semi purposeful behaviors of which the patient is
unaware and subsequently cannot recall.
7
Four syndromes are Associated With Typical Absence Seizures
• Childhood absence epilepsy
• Juvenile absence epilepsy
• Epilepsy with Myoclonic absences
• Juvenile Myoclonic Epilepsy
Atypical Absence Seizure
• Diminished postural tone, or tonic or myoclonic activity
• Automatisms are less likely
• Longer duration than typical absences
• Atypical absence seizures have lennox- Gastaut syndrome.
Electroencephalographic Findings
• Typical absence seizure, the sudden onset of 3-Hz generalized
symmetric spike-and-wave or multiple spike-wave complexes maximal
in the frontal-central regions.
• Atypical absences, the ictal EEG is more heterogeneous, showing
1.5 - 2.5 – Hz slow spike-and-wave or multiple spike-and-wave
discharges that may be irregular or asymmetric.
CLONIC SEIZURES
Clinical Features
Clonic seizures are similar to generalized tonic-clonic seizures but are
characterized by only rhythmic or semirhythmic contractions of a group of
8
muscles. These jerks can involve any muscle group, although the arms, neck,
and facial muscles are most commonly involved.
TONIC SEIZURES
Clinical Features
Tonic seizures are brief seizures consisting of the sudden onset of
increased tone in the extensor muscles (14).
Tonic seizures frequently are seen in patients with lennox-Gastaut
syndrome.
EEG Findings
The EEG ictal manifestations of tonic seizures usually consist of
bilateral synchronous spikes of 10 to 25 Hz of medium-to-high voltage, with a
frontal accentuation.
ATONIC SEIZURES
Clinical Features
Atonic seizures, or “drop attacks,” are characterized by a sudden loss of
muscles tone (16). They begin suddenly and without warning and cause the
patient, if standing, to fall quickly to the floor. Children with atonic seizures are
more likely to fall backward than children with atonic seizures. Because muscle
tone may be completely absent, the children have little means by which to
protect themselves, and injuries often occur.
9
LENNOX-GASTAUT SYNDROME
Lennox-Gastaut syndrome is characterized by a mixed seizure disorder.
Of which tonic seizures are a major component (15). Mental retardation is
present before onset of seizures in 20% to 60% of patients.
Electroencephalographic Findings
The slow spike-and-wave or sharp-and-slow-wave complexes consist of
generalized discharges occurring at a frequency of 1.5-2.5 Hz.
Etiology
Primary refers to cases in which the etiology is idiopathic, whereas
secondary refers to cases in which the disorder is symptomatic of a definable
etiology.
Disorders Commonly Associated with Lennox-Gastaut Syndrome
Prenatal Perinatal Postnatal
Cerebral dysgenesis Hypoxia/ischemia Meningitis/encephalitis
Tuberous Sclerosis Intracranial hemorrhage Postinfectious
Congenital infection Cerebrovascular Disease
Stroke Hypoxia/ischaemia
Status epilepticus
Head injury
Hypoglycaemia
Degenerative disorders
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FOCAL AND MULTIFOCAL SEIZURES
Focal or partial seizures originate in one region of the brain, where they
may stay confined or spread to other areas. Multifocal seizures arise from
multiple locations and constitute an important type of seizure in infancy and
childhood. It constitutes 60% of all seizure disorder (17). In a majority of
children with focal seizures, no focal structure lesion is present and the seizures
either are the expression of an idiopathic disorder (benign roloandic epilepsy)
INTERNATIONAL CLASSIFICATION OF SEIZURE DISORDERS
(MODIFIED)
Classification of Focal Seizures
A. Simple partial seizures
Clinical seizure type: Simple partial seizures, consciousness not impair
ed.
EEG ictal discharge: Local contra lateral discharge starting over the
corresponding area of cortical representation (not always recorded on the scalp;
broad, diffuse rhythms possible when the source is deep).
EEG interictal expression: Local contralateral interictal epileptiform
discharge, and pleomorphic ( or varied) with associated slowing when
associated with symptomatic etiologic disorder.
1. With motor signs
a. Focal motor without march
b. Focal motor with march ( jacksonian)
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c. Versive (Adversive)
d. Postural
e. Phonatory (Vocalization or arrest of speech)
With autonomic symptoms (including epigastric sensation, pallor,
sweating, flushing, piloerection, and papillary dilation)
2. With somatosensary or special sensory symptoms (simple hallucinations,
E.g., tingling, light flashes, buzzing)
a. Somatosensory ( Post Central gyrus)
b. Visual
c. Auditory
d. Olfactory(uncinate fits)
e. Gustatory
f. Vertiginous
3. With psychic symptoms (disturbance of higher cerebral function); rarely
occur without commonly such as complex partial seizures
a. Dysphasic
b. Dysmnesic (e.g., deja vu)
c. Coginitive (e.g., dreamy states, distortions of time sense)
d. Affective (i.e., fear, anger, and other emotional states)
e. Illusions (e.g., macropsia)
f. Structured hallucinations (e.g., music, scenes)
12
B. Complex partial seizures
Clinical seizure type: Complex partial seizures, with impairment of
consciousness, sometimes beginning with simple symptoms.
EEG ictal discharge: Unilateral or frequently bilateral discharge,
diffuse or focal in temporal or frontotemporal regions.
EEG inter ictal expression: Unilateral or bilateral, generally
asynchronus focus; usually in the temporal regions.
1. Simple partial onset followed by impairment of consciousness
a. With simple partial features (described in part A) followed by
impaired consciousness
b. With automatisms
2. With impairment of consciousness at onset
a. With impairment of Consciousness only
b. With automatisms
c. Partial seizures evolving to generated tonic-clonic seizures
Clinical seizures type: Generalized tonic-clonic seizures with partial or
focal onset
EEG ictal discharge: Discharge like those for complex partial seizures,
becoming secondarily and rapidly generalized.
1. Simple partial seizures evolving to generalized tonic-clonic seizures.
2. Complex partial seizures evolving to generalized tonic-clonic
seizures.
13
3. Simple partial seizures evolving to complex partial seizures evolving
to generalized tonic-clonic seizures.
d. Partial seizures with uncertain alternation of consciousness
(useful for infants and other special populations)
EEG ictal discharge: Behavioral arrest seizures often are accompanied
by rhythmic discharge in the temporoparieto-occipital region. Clonic seizures
have a contralateral ictal expression, usually consisting of repetitive spikes,
spike-and-wave discharges, or highly rhythmic delta. Spasms themselves area
associated with electrodecrements, but focal seizures may precede, accompany,
or follows the cluster. Tonic postures often are accompanied by diffuse
attenuation or lowvoltage fast patterns. Versive seizures in the younger
population often have a posterior quadrant correlate
Interictal EEG expression: Pleomorphic interictal epileptiform
discharges and focal slowing may be seen. In the immature infant, it is
common to observe multifocal spikes, even in the setting of focal structural
lesions. Here, focal slowing, attenuation, or both are useful features indicating
a focal process.
1. Behavioral arrest
2. Clonus: focal or unilateral
3. With associated spasms (may come before, during, or after the cluster)
4. Tonic
5. Versive
14
SEIZURE SEMIOLOGY INDICATING A FOCAL SEIZURE
1. Aura
2. Behavioral arrest (in most cases, although patients with absence also
have behavioral arrest)
3. Focal clonus
4. Focal dystonic posture
5. Focal limb automatisms
6. Spasms (approximately one fourth of patients with spasms have
associated focal seizures)
7. Tonic postures (particularly asymmetric tonic posture, although
symmetric tonic postures also seen infants with seizures)
8. Version (involving the head, eyes, or both)
ETIOLOGY
Partial seizures are more likely to be associated with focal hemispheric
lesions.
1. Cortical Malformations
Of particular importance for focal seizures are focal and hemispheric
malformations including cortical dysplasia (Taylor types I and II),
schizencephaly, isolated heterotopias, and hemimegalencephaly. Patients with
lissencephaly may have focal seizures, but the widespread nature of the
malformation places patients with this disorder in the generalized symptomatic
epilepsy syndrome category.
15
2. Congenital and Perinatal Factors
Chromosomal pathologic conditions may result in malformations.
Intrauterine infections, specifically cytomegalic inclusion disease,
toxoplasmosis, and rubella, are well known for their ability to cause abnormal
brain development, Syphilis, rare in many parts of the world, also may cause
intrauterine brain infection, with serve neurologic residua. Maternal exposure
to radiation during pregnancy or ingestion by the mother of teratogenic drugs
also may lead to cerebral malformations. Tuberous sclerosis may manifest
during the first few months of life and may be accompanied by focal seizures
or infantile myoclonic spasms.
3. Brain Tumors
Tumors that are relatively less malignant and slow growing are more
often associated with seizures than are malignant tumors. Focal seizures
accompanied by a history of headaches may be caused by tumor.
4. Postnatal Infectious Diseases
a. Seizures often are the first indication of bacterial meningitis
b. Focal or multifocal seizures may be associated with viral
encephalitis.
c. Diphtheria-pertussis tetanus immunization
d. Parasitic infestation, Neurocysticercosis/ Echinococcosis
e. Tuberculosis with tuberculoma formation
16
5. Trauma
Focal seizure may result from subdural hematomas in childhood;
multifocal seizure can result from bilateral sub-dural hematomas.
6. Cerebrovasuclar Disease
SWS usually manifests with a port-wine nevus in the distribution of one
or more divisions of cranial nerve V. The associated angiomatosis is found
over the ipsilateral cortex in the pia-arachnoid. The associated gyri are
atrophied, and linear calcifications may be present, most often in the occipital
lobes.
Congenital heart disease or bacterial endocarditis may cause emboli that
flow to the brain and precipitate seizures.
Considerations in the differential diagnosis of early onset hemiplegia
include fibromuscular hyperplasia, intraoral trauma to the internal carotid
artery, carotid artery dissection, and arteritis.
Moyamoya disease and mitochondrial disorders, sickle cell disease,
circulating lupus anticoagulant, and homocystinuria may produce similar
insults.
MYOCLONUS, MYOCONIC SEIZURES AND INFANTILE SPASMS
Definition
Myoclonous(from the Greek Myo”muscle” and Klonus
“agitation/Violent contraction” has been defined as a “sudden ,involuntary
shock like muscle contraction arising from the central nervous system”(21).
17
OVERVIEW OF MYOCLONUS CATEGORIES
Classification of Myoclonic Seizures and Syndromes
Myoclonic Seizures of Infants, Children and Adolescence
Infants
Early infantile epileptic encephalopathy
Benign Myoclonic epilepsy of infancy
Severe Myoclonic epilepsy of infancy
Infantile spasms
Storage disorders
Mitochondrial disorders
Other progressive entities
EPILEPTIC NONEPILEPTIC
INHERITED ACQUIRED
Benign primary epilepsy syndrome (e.g.,JME) Severe Myoclonic epilepsy syndromes Progressive Myoclonic
Anorexia,Head Trauma,Tumors,Uremia and other metabolic encephalopathies,Degenerative CNS Disease Stroke,Viral Infections.
18
Children and Adolescents
Familial Myoclonic epilepsy
Myoclonic seizures in Lennox –Gastaut syndrome
Absence with Myoclonic features
Juvenile Myoclonic Epilepsy
Mitochondrial disorders
Progressive Myoclonic epilepsies
Degenerative /Storage disorders
Syndromes of Infants: Infantile Spasms (West’s Syndrome)
Infantile spasms occurs primarily during the first year of life especially
between the third and eight months, regardless of the timings of any instigating
factors (e.g., intrauterine infection or stroke, tuberous sclerosis, perinatal
asphyxia, postnatal insult).Infantile spasms were first brought to attention by
Dr.W.J.West in 1841,who documented the disorder in his own son(22). The
movements may consists of head and body flexion with leg extension.
EEG Findings: The presence of hypsarrhymia, a disorganized, high
voltage pattern with no normal background.
PEDIATRIC NEURO IMAGING
A clear understanding of various types of seizure in children and
knowledge of normal neuroanatomy and its alternations in various disease
process are prerequisites for the correct performance and interpretation of the
19
many powerful neuroimaging technique that are available. Different modalities
of neuroimaging techniques continue to evolve, with better resolution in 2D
sand 3D depiction of anatomy and its aberrations in disease processes in the
field of pediatric USG, CT and MRI. Even though these remain the mainstay of
Pediatric Neuroimaging, the techniques, interpretation and usefulness of
functional neuroimaging have been improved by development of other methods
including DWI, MRS, SPECT, PET and fMRI.
CRANIAL ULTRA SOUND
Sonography is portable, fast, and multiplaner, and it can be performed at
the bedside. Pulses of non-ionizing ultra sound at a frequency of 3.5 – 10 MHz
are applied by a transducer to the area of interest. The ultrasound waves are
reflected at different amplitudes from organ and tissue interfaces. A reflected
sound waves or Echo is represented as a dot, with the gray shade or brightness
of the dot proportional to the strength of returning Echo and the location of the
dot related to the depth of the reflecting structure.
� B – Mode Scanning (Brightness Mode)
� Real – Time ,Gray – scale sonography
� Duplex Doppler/Color Doppler Ultrasonography.
USG can screen for developmental malformation and for intrauterine
infections and to determine the cause of an enlarging or enlarged head.
Real – time sonography can display echogenic (Bright) structure, such
as choroid plexus, hemorrhage, some tumors, and focal areas of cerebritis, and
20
sonolucent structures, such as CSF in the ventricles, subarachnoid spaces, cysts
and cystic lesions.
Lesions containing CSF or CSF – filled like contents are well delineated
because of the echo lucency of water. eg., ventriculomegaly, porencephaly,
Dandy- Walker syndrome, arachnoid cyst and Encephalocele. Vascular
malformations, aneurysm of Vein of Galen, can be well demonstrated with
color Doppler USG. Major migrational anomalies, such as agyria – pachygyria
and lissencephaly, may be delineated by USG; however smaller heterotopias or
other subcortical dysplasias may be overlooked. USG is helpful in the
evaluation of a newborn suspected of having TS as it can detect the intra
cranial hamartomas or subependymal nodules.
COMPUTED TOMOGRAPHY
CT has been available since the 1970 for clinical use in children.
Ionizing radiation due to X - ray CT is effectively restricted to the immediate
body part of interest by the tight collimation used to create the thin fan beam
used for scanning.
Helical CT Axial
Multidetector CT Coronal plane
Multislice CT Multiplaner
21
Each CT examination contributes to the lifetime exposure. It is
necessary to limit radiation from CT in children and follow the ALARA
principle.
The digital demographic image is composed of a matrix of voxels. Each
voxel is assigned a numeric value called a CT Number, which is related to the
tissue density. Most system express CT number in Hounsfield units, with water
used as a references and assigned a value of zero. Fatty tissues with less than
water have Negative CT Number; whereas positive CT number indicate a
tissue density greater than water. Most soft tissue elements have positive CT
Number.Calcium, mineralized bone, and concentrated blood elements higher
than most soft tissues. CT is limited by streaking artifacts in areas adjacent to
thick bone or metallic objects such as dental fillings and gunshot wound
pellets.
Abnormalities can be characterized with CT as having low density,
isodensity, or high density in relation to the Brain. Lesions that appear lower in
density include edema, necrosis, infarction, neoplasms, leukodystrophies,
Inflammations, and cysts. Loss of gray white matter differentiation may be
seen with diffuse brain edema after hypoxic ischemic injury on a demyelinating
process. Fat containing lesions usually appears less dense than water or of
mixed density, as in patients with a teratodermoid type of tumors. Air appears
as the lowest density and can be seen in pneumocephalus lesions. Isodense to
normal tissue are difficult to recognize unless there are change that demonstrate
22
displacement or replacement of normal anatomic structure. Intravenous
contrast material that helps to separate the lesions from normal structures.
High density lesions seen in hemorrhage or the presence of calcium.
Pathologic intra cranial calcifications can be seen with Congenital infections,
Neurocysticercosis, Intracranial tumors, TS, SWS, NF, Cockayne’s syndrome,
hypoparathyroidism, AV malformations, Vein of Galen malformations,
Encephalomalacia, Cerebral infraction, or the sequelae of perinatal asphyxia.
Hypercellular neoplasms with high nuclear - Cytoplasmic ratios
(Medulloblastomas, other primitive neuro ectodermal tumors, germinomas,
lymphomas) may also appear as high density lesions on CT.
In neurodegenerative diseases of childhood, CT may reveal decreased
attenuation in the basal ganglia and cerebral white mater of focal or generalized
cerebral atrophy. CT can be helpful in evaluating NCS to detect calcification as
in TS.
Contrast enhanced CT is helpful in the evaluation of suspected or known
Vascular malformations, neoplasms, abscesses and Empheymas.
MAGNETIC RESONANCE IMAGING
MRI uses magnetic fields and radiofrequency pulses to obtain high-
resolution images of the body. Hydrogen nuclei are used to generate detectable
signals in MRI. MR images are created by sending radiofrequency pulses into
patients lying in an external magnetic field, thereby perturbing hydrogen nuclei
in to producing signals of various intensities from different body tissues. In
23
MRI the resulting signals are mapped onto a gray-scale digital image. The
intensity of the signals produced in MRI are determined by several factors,
such as the photon density, the mobility of the photons within the molecular
lattice (T1 relaxation), and the effect of local magnetic field produced by
magnetic nuclei within the tissue (T2 relaxation).
Tissue with short relaxation times, such as Fat and intercellular and
extracellular metHb, produce high signal intensity on T1 weighted images.
CSF, muscle, deoxyHb, and Hemosiderin, tissue of substances with long T1
relaxation times, appear dark on T1 weighted images, Tissues or structures with
long T2 relaxation times, such as CSF, edema, many tumors, Extra cellular
metHb, infracts and multiple sclerosis plaques, are bright on T2-weighted
images, whereas tissues or substances such as muscle, Cortical bone, deoxyHb,
and hemosiderin are dark as a result of short T2 relaxation tissues.
Pathologies includes migrational anomaties, such as gray-matter
heterotopias, closed-lip Schizencephaly, Lissencephaly, Pachygyria and
hemimeganencephaly, and NCD, such as NF, that are not seen well on CT are
better demonstrated with MRI.
MRI is useful in the evaluation of patients with movement disorders
such as Wilsons ds, it demonstrates abnormal T2 signal in the basal ganglia(27),
and in Huntington’s ds revealing atrophy of the caudate nuclei and increased T2
signal in atrophic caudate nuclei. In panthothenate kinase deficiency
(Hallervorden-spatz sydrome), MRI demonstrates areas of symmetric low
24
signal intensity in the antero lateral aspect of the globus pallidus, so called Eye
of tiger sign. MRI shows multi focal cortical infarctions and the presence of
lactate peaks in photon MR Spectroscopy in Mitochondrial disorders, such as
MELAS. In other Mitochondrial disorders, such as MERRF syndrome, Kearns-
Sayre Syndrome, Leigh’s syndrome, Alpers’ds, and Menke’s ds, symmetric
white matter T2 hyperintensities with involvement of deep cerebral nuclei are
observed on MRI.
For focal and diffuse white matter disease, T2-weighted MRI is more
sensitive then CT. MRI should preferentially be used to evaluate children with
ADEM, HIV Encephalitis, and Sickle cell disease, Vasculitis such as SLE,
lyme ds, PMFL and multiple sclerosis. Recognizable patterns of while matter
involvement can be seen with MRI in certain inherited lenkodystrophies. For
example, early diffuse involvement of the peripheral subcortical white matter is
seen in Pelizaeus – Merzbacher ds, Canavan’s ds, and Alexander’s ds. In
Canavan’s ds, on photon MR Spectroscopy, a larger than normal NAA peak is
produced. In Alexander’s ds, there in predilection for T2 lengthening in frontal
while matter and enhancement after contract. Predilections for occipital while
matter involvement is seen with ALD. In globoid cell Lenkodysrophy
(Krabbe’s) T2 hyperintensity can be seen in Cerebellum and deep cerebral
white matter, whereas the thalami and basal ganglia may be hypointense.
MRI can demonstrate mesial temporal Sclerosis, and can reveal small
tumors in the aqueduct, Sella turcica or brainstem even when the CT is normal.
25
High resolution images of the brain capable of detecting of lesions not
identified with standard MRI, including hippocampal dysplasia, hippocampal
atrophy, and dual pathology with cortical dysplasia.
MRI is the procedure of choice when children present with symptoms
and signs that suggest CNS tumor.
For vascular and Hemorrhagic lesions, MRI is more specific. MRA then
added a new dimension to the evaluation of pediatric Cerebrovascualr disease.
This imaging technique can be used to evaluate vascular malformations, vaso-
occlusive ds, and vascular neoplasms.
MRI may detect silent infarction in children with Kawazaki’s ds or
Sickle cell ds. MRI can differentiate arterial from venous occlusive disease. In
evaluating ICH caused by angiographically occult lesions such as cavernous
angiomas, MRI in the procedure of choice. Special MRI sequences are
available that can differentiate CSF containing lesions (arachnoid Cysts) from
other lesions (Epidermoid tumour).MRI is excellent in delineating midline
abnormalities including lesions in the Sella, aqueduct, Foramen magnum, and
pineal region,
MAGNETIC RESONANCE SPECTORSCOPY
MR Spectroscopy is clinically useful, non-invasive tool for indentifying
the biochemical state of the CNS. Certain atomic nuclei such as H (Photons)
are magnetic, and when exposed to a strong magnetic field, they align in a
particular orientation until equilibrium is reached. If the nuclei are then excited
26
by a radiofrequency pulse at their resonant frequency, they produce a
detectable signal during relaxation back to equilibrium. During relaxation,
because of their local chemical environment, each photon produces a signal at a
slightly different frequency, called a chemical shift. After a Fourier transform
analysis, the plots of the resulting nuclear spectra appear as peaks of signal
intensity versus signal frequency on chemical shift.
Small concentrations of metabolites, such as Creatine, Cho, NAA,
lactate and many amino acids can be detected using acquisition sequences.
Spectral Metabolites Using Proton Magnetic Resonance Spectroscopy
Proton MR Spectroscopy in being used to investigate a wide range of
Neurologic disorders. Metabolites measured with H-MR Spectroscopy include
NAA, a neural marker, Creatine composed of phosphocreatine and its precursor
creatine which are bio energetic metabolites; .Cho- Containing compounds
including free cho and phosphoryl and glycerophosphoryl cho that are released
during membrane disruption; lactate, which accumulates in response to tissue
damage or anaerobic glycolysis; and glutamate and immediately formed
glutamine and myoinositol an osmolyte and astrocyte marker.
Diseases Studied with Photon Magnetic Resonance Spectroscopy
Protons MR Spectroscopy combined with MRI is useful in screening
children for metabolic and mitochondrial disorders based on the detection of
increased cerebral lactate level or the presence of other elevated metabolic
27
peaks(23). Abnormalities have been reported in pts with glutaric aciduria type 2;
pyruvate dehydrogenase deficiency, Leigh’s syndrome; XL ALD. In
phenylketonuria, elevated phenylalanine level. In canavan’s ds, an elevated
NAA peaks and have abnormally increased NAA/ creatine and NAA/Cho
ratios. Leigh’s ds, MRS reveals an abnormally high lactate peak and &
decreased NAA peak in Basal ganglia.
Localized proton MRS have indicated decreased NAA, increased Cho,
and increased lactate levels in epileptic foci compared with nonictal or
contralatetal regions.
Malignant pediatric brain tumors are characterized by an increase in
cho/ NAA ratio and a decrease in NAA/ creatine ratio.A general decrease in the
NAA and creatine peaks and an increase in Cho. Cho signal intensities are
highest in astrocytomas and anaplastic astrocytomas, and creatine signal
intensities were lowest in glioblastomas. Proton MR Spectroscopy may be
useful in differentiating various types of cerebellar tumors, such as primitive
neuroectodermal tumors, low grade astrocytomas, and ependymomas.
DIFFUSION- WEIGHTED IMAGING
DWI is technique that uses MRI to measure the diffusion of water
through tissues. Random displacement of water molecules (i.e. diffusion) are
modified by structural and physiologic factors in the medium. In a medium in
which diffusion of water molecules is identical in all directions the process
called ISOTROPIC diffusion. When the process depends on direction, it is
28
called ANISOTROPIC diffusion. DWI has been used to investigate stroke and
hypoxic-ischemic injury in children, to differentiate solid from cystic CNS
lesions and to evaluate patients with demyelinating disease.
DWI is useful in differentiating cystic brain tumors (high ADC) from
epidermoid tumors(lower ADC).
In XL ALD, significant abnormalities with diffusion tensor imaging that
are not seen on conventional MRI. In case of B12 deficient
lenkoencephalopathy, reduced anisotropy occurred within white matter lesions
with T2 abnormalities. DWI can detect larger areas of involvement than
conventional MRI in demyelination process. In patients with sickle cell disease
and in acute CNS event like,acute CO poisoning, dural sinus thrombosis, acute
infarct DWI is an essential part of the investigations.
Children with new onset prolonged seizure can develop unilateral
hippocarnpal sclerosis. The presense of diffusion restriction in the affected
hippocampal region can herald subsequent development of MTS(26).
DWI may show diffusion restriction in solid portions of PNET, a finding
unusual in non PNET(25). Hyper intensities can be seen in lymphomas on DWI.
DWI is useful in evaluating children with intra cranial infection cerebral
abscesses, uberculomas, subdural empyemas, epidural abscesses demonstrate
hyperintensity with DWI. Naeurocysticercosis and encephalitis appear
hyperintense whereas toxoplasmosis lesions produce variable signal intensity.
29
DWI is helpful for the early diagnosis of stroke, reveals hyper intensity
in an acute infarct soon after the onset of ischemia.
PERFUSION MAGNETIC RESONANCE IMAGING
PWI is an extension of MR technology that allows evaluation of blood
volume, blood transit time and blood flow as relative measures. Two technique
have been developed
1. Dynamic Contrast - Enhanced Susceptibility-Weighted Perfusion
Imaging
It can be used to image relative differences in blood volume over time.
2. The Blood Oxygen Level – Dependent Technique
It can be used to quantify cerebral blood flow:
� It can demonstrate regions of Acute ischemia before lesions are
detectable by MRI.
� In patient with Sickle cell disease, abnormalities on PWI are
associated with neurologic symptoms although the areas of
abnormalities may not be seen in conventional MRI, MRA or
transcranial Doppler study.
� PWI has also been used to differentiate tumor types.
� PWI also helpful in children with ADEM, Cerebral AV
malformations and other proliferative angiopathies.
30
SUSCEPTIBILITY-WEIGHTED IMAGING
A sequence using a high-spatial-resolution, 3D, Fast, low-angle MRI
technique that is extremely sensitive to Susceptibility.
� SWI has been very useful in detecting hemorrhagic lesions
associated with DAI. This technique can also be used to categorize
tissue as normal appearing or with non-hemorrhagic or hemorrhagic
injury.
� This blood – Sensitive Sequence has been found to be extremely
valuable in detection of hemorrhage in children with accidental or
non-accidental trauma, infarctions, tumors, Proliferative angiopathies
and Vascular malformations, including SWS, Cavernous angioma
and in patients with hypertensive encephalopathy.
FUNCTIONAL MRI
fMRI is a technique that measures changes in tissue perfusion based on
changes in blood oxygenation. It is used to study regional brain activity in
response to sensory, motor and Cognitive stimulation.
fMRI in being used in patients with various neurologic diseases,
including medically refractory epilepsy and brain tumors.
31
MAGNETIC SOURCE IMAGING
MSI uses magnetoencephalography(MEG). When Source localizations
modeled from the magentoencephalographic signal are registered with high
resolution, and it displays functional information in an anatomic context.
MEG is powerful and accurate tool for the pre – surgical evaluation of
children with refractory epilepsy, and pre-operative localization of epileptiform
activity.
MEG helpful in evaluating patients with dyslexia. MEG provides
additional information regarding the spatial relation between brain lesions and
functional cortex.
SOLITARY SINGLE RING ENHANCING LESION OF BRAIN (48)
A. Neoplasms
1. Primary Neoplasm
a) High Grade Glioma
b) Meningioma
c) Lymphoma
d) Leukemia
e) Pituitary macroadenoma
f) Acoustic neuroma
g) Craniopharyingioma.
2. Metastatic carcinoma and sarcoma
32
B. Infection /Inflammation
1. Bacterial fungal parasitic
2. Empyema of epidural / subdural / intraventricular spaces.
C. Hemorrhagic-Ischemic Lesion
1. Resolving Infarction
2. Aging hematoma
3. Thrombosed aneurysm
4. Operative bed following resection.
D. Demyelinating Disorder
1. Radiation necrosis
2. Tumefactive demyelinating lesion
3. Necrotizing leukoencephalopathy after methotrexate
Single small contrast enhancing CT lesion (SSECTL) is the commonest
presentation in neuroimaging study. The commonest etiology is
neurocysticereosis followed by tuberculomas.
NEUROCYSTICERCOSIS
Neurocysticercosis (NCC) is a major cause of neurological disease
world-wide(28,29). It is an important cause of epilepsy in the tropics(30) and was
found to be the commonest cause of focal seizures in North Indian children(31).
Neurocysticercosis is caused by infestation of the CNS with encysted
larvae of Taenia solium.
33
The cyst has 4 stages
1. Vesicular Stage (Metacestode): The parasite lives in tissues as a fluid-
filled cyst with a thin semitransparent wall. The scolex lies invaginated
on one side of the cyst and appears as an opaque 4-5 mm nodule. These
viable cysts are generally asymptomatic. Once the cysts start
degenerating, an inflammatory response is elicited and the cyst goes
through the following stages.
2. Colloidal stage: The larva undergoes hyaline degeneration and
gelatinous material appears in cyst fluid.
3. Granular nodular stage: The cyst contracts and the walls are replaced
by focal lymphoid nodules and necrosis.
4. Nodular calcified stage: The granulation tissue is replaced by
collagenous structures and calcification.
Most children present with partial seizures(32, 33, 34) particularly complex
partial seizures(32); about a quarter have simple partial seizures. Most seizures
are of short duration, generally lasting for less than 5 minutes.
Diagnosis: Diagnosis rests mainly on neuroimaging.
CT scan: Parenchymal NCC
Vesicular cysts: It is generally appear as small round lesions with CSF
density cystic fluid; the wall is isodense to the brain parenchyma. They are
non-enhancing or mildly enhancing and are not surrounded by edema.
34
Degenerating (colloidal vesicular) cysts: It appears as small low-
density lesions with ring or disc enhancement. The scolex appears as a bright
high density eccentric nodule in these cysts and is pathognomonic of NCC.
Perilesional edema of varying grades is seen in over half the cases. In most
cases the lesions are single and <20mm in size-termed as single small
enhancing computed tomographic lesion (SSECTL)(35). Some children may
have multiple lesions; disseminated NCC with numerous cysts may give the so
called “starry –sky” appearance which is typical of NCC.
Calcified cysts: They are few mm in size, single or multiple and
generally without any surrounding edema. However in children with active
seizures, edema may at times be seen around calcified lesions.
MRI
Identification of scolex and visualization of extraparenchymal cysts is
better with MRI. Live cysts are seen as round lesions either isointense or
slightly hyperintense to the CSF. The scolex is seen as a nodule that is
isointense or hyperintense relative to white matter. On T2 weighted images, the
perilesional oedema appears bright and because of the high intensity cystic
fluid, the scolex may not be seen. The scolex is better seen on proton density –
weighted images. Gadolinium enhanced MRI shows ring enhancement of
lesion. Calcified lesions appear hypointense on all MR imaging sequences and
may at times be missed(36). MRI is more sensitive for detecting scolex and
35
extraparenchymal NCC(37). In cases where the scolex is not well seen, other
sophisticated imaging techniques are therefore being researched.
Proton Magnetic Resonance Spectroscopy (MRS)
MRS has been tried for evaluation of inflammatory granulomas(38). It
has been suggested that presence of lipid indicates a tuberculoma whereas low
levels of metabolites together with a poor signal/noise ratio could indicate
NCC.
3D Constructive Interference In Steady State (3DCISS)
It is found to be more sensitive and specific than routine SE sequences
in the diagnosis of intraventricular cysticercal cysts.-scolex(39).
DWI MRI
High (ADC) is seen in core of cysticercus cysts compared to
tuberculomas and tubercular abscess(40).
TUBERCULOMA
Primary TB infection is usually pulmonary and is followed by lymphatic
drainage of bacilli to regional lymph nodes. Further drainage of bacilli via the
thoracic duct into the venous system occurs giving low grade or “silent”
bacillemia(41,42). Massive bacillemia is precipitated by a tuberculous focus,
often a lymph node, eroding and discharging into a blood vessel. The brain is
infected by this hematogenous disseminationand meningeal involvement is
36
secondary to rupture of a parenchymal tuberculoma into the subarachnoid
space, rupture of a tuberculoma in a vessel related to the subarachnoid space or,
very rarely, via contiguous spread from bone involvement by TB(43). Most
children present with partial seizures particularly complex partial seizures;
about a quarter have simple partial seizures.
IMAGING
CT Scan
Focal parenchymal tuberculomas measure 5-30 mm but are occasionally
larger, up to 60 mm. 15-20 % present with multiple, separate lesions although
grape-like clusters of granulomas occur. Tuberculomas may occur anywhere in
the parenchyma but have a tendency to be peripheral. A typical symptomatic
tuberculoma has surrounding vasogenic edema and central necrosis. The
increased interstitial space fluid of vasogenic edema is hypodense on CT.
MRI Scan
The granuloma is iso- to hyperdense on CT and on MR is slightly T1
hyperintense with marked T2 hypointensity. Small granulomas, up to 10 mm,
will enhance diffusely following IV contrast on CT and on T1Gad images. This
is consistent with the vasoformative component of the inflammatory process
and the absence of (macroscopic) necrosis. Necrosis, usually central, is
associated with loss of enhancement and results in ring-enhancing lesions.
Other causes of SSECTL like Neoplasms, Hemorrhagic – ischemic
lesions and Demyelinating disorders are very rare findings in Neuro Imaging.
REVIEW OF LITERATURE
37
REVIEW OF LITERATURE
There are many studies are available to know about seizures pattern in
adult population, but studies are limited in pediatric population. Few studies
about seizures pattern includes, Camfield et al., 1996b; Hauser et al., 1993(2).
Studied the incidence childhood epilepsy. Studies stated that the incidence in
the first year of life is about 120 in 1akh. Between 1 and 10 years, the incidence
plateaus at 40-50 cases in children and then drops further in the teenage years
to about 20 in 1 lakh.
Eriksson et al., 1997(3). Studied a population based prevalence study
from Finland, found that the main seizure types for each patient were focal in 43%, with
complex partial and partial with secondary generalization most common. For 44%,
generalized seizure were dominant, with generalized tonic-clonic seizures most
common. Overall, 45% had localization related epilepsy syndromes, and 48%
had generalized syndrome.
Hauser and Kurland., 1975(6). Studied an Epidemiological study,
found that primary generalized seizure accounted to be 40.5%. Of the primary
generalized seizures, generalized tonic-clonic are the most common followed
by absence and myoclonic seizure.
Juul-Jensen and Foldspang., 1983(49). An Epidemiological study, they
found that primary generalized seizure accounted for 45.8% of the seizure
types.
38
Tapani keranen et al., 2007(45). Studied an epidemiological survey of
1220 patients over 15 years of age. Stated 56% of patients had partial seizure.
Sub classification of partial seizures revealed SPS in 7.5% of cases, CPS in
23%, and PSGS in 25.5% of the cases.
DiMauro and Moraes., 1993(50). Observed that among the
mitochondrial disorders, myoclonic epilepsy with ragged red fibers may
manifest as myoclonic seizures in children adolescents.
Studies regarding seizure disorders and neuroimaging findings includes
Hirtz et al., 2001(51). Analyzed all patients presenting with their unexplained
generalized tonic-clonic seizure, with the recognition that in patient with
normal neurological examination. He observed that the chance of finding a
treatable lesion in neuro imaging is quite low.Beig et al., 2000a (18). Studied
613 children had symptomatic localization related epilepsy. 117 of 613
children had abnormal finding on MRI (28.3%).
Another study regarding seizures and neuroimaging findings, Fariba
Khodapanahandeh and Homayon Hadizadeh., 2006(46). Studied 125
children aged between 1 month – 15 years. Of which 22% patients presented
with focal and 78% with generalized seizures. Out of 27 patients with Focal
seizures, Eight (30%) and out of 92 with generalized seizures, only four (4%)
had abnormal findings (Fisher Exact test, P< 0.001).
Single solitary enhancing CT lesions are the most common
neuroimaging abnormality in developing countries. Studies are conducted in
39
some developing countries regarding tuberculosis and nurocysticercosis. that includes,
Singhi P., et al 2009(32). Studied of 500 children with neurocysticereosis. It showed most
children present with partial seizures (84-87%) particularly complex partial
seizures; about a quarter had simple partial seizures.
Export Committee on Pediatric epilepsy, Indian Academy of
Pediatrics(44), Stated that new onset partial or generalized convulsive seizures
occurring in clusters in an otherwise normal child, single small contrast enhancing CT
lesion (SSECTL) is the commonest presentation in neuroimaging study. The
commonest etiology is neurocysticereosis followed by tuberculomas.
Pratibha Singhi, et al., 2009. Observed that neurocysticercosis is a
major cause of neurological disease worldwide(28,29) it is an important cause of
epilepsy in the topics(30) and was found to be commonest cause of focal
seizures in North Indian Children(31).
Berg et al., 2000a(18). The study showed only 4(0.6%) of 613 children
with Epilepsy had a brain tumor in his large epidemiological study of 613
children.
Sachdev et al., 1991(55). The commonest age group for Solitary single
enhanced CT lesions between 5-8 years.Sethi et al., 1985(56) and Goulatia et
al., 1987(54). Solitary single enhancing CT lesion Sex distribution Male:
Female = 5:4. Sachdev et al., 1991(55) showed SSECTL 95% in parietal lobe,
3% in Frontal lobe, 1% in Temporal lobe..Srinivas et al., 1992(57). Showed
40
SSECTL 95% seen in parietal lobe followed by 3% in occipital lobe and 2% in
temporal lobe.
D.H. Jamieson et al., Springer-Verlag., 1995(47). Evaluated that
calcifications are rarely noted in tuberculoma. Calcification is more commonly
associated with cysticercus granulomas. It can be dedected in CT.Douglas R.
and Nordli., Kenneth F. Swaiman 2006(53). Stated as only 10% children with
focal seizures have brain tumors or stroke in neuroimaging.
STUDY JUSTIFICATION
41
STUDY JUSTIFICATION
Seizures are the most common neurological disorder in Pediatric age
group and occur in 10% of children (58). Several times, a child may present with
a condition that can mimic or be misinterpreted as a seizure. A seizure has to be
differentiated from these conditions as misdiagnosis can have significant
therapeutic implications. Neuro imaging used in pediatric population with new
onset seizures for identification of underlying pathologies and to aid
formulation of syndromic and etiological diagnosis. The entity of single small
enhancing CT lesion (SSECTL) brain in children with seizures has confounded
clinicians for a long time. There are contradicting views about the cause and
management of these lesions both in Indian and other literature. The purpose of
the study is intended to know the prevalence of various seizure types and its
neurological imaging finding in our population and guide the clinicians about
the prevalence state of various seizure types and various disease prevalent
states in our population.
OBJECTIVES
42
OBJECTIVE
1. To study the various pattern of seizure disorders.
2. To study the neuroimaging findings in seizure disorders
METHODOLOGY
43
METHODOLOGY
MATERIALS
STUDY PLACE : K.A.P.V.Govt.Medical college and
Annal Gandhi Memorial Govt. Hospital,
Department of Pediatrics,
Thiruchirappalli.
STUDY DESIGN : Descriptive study
STUDY PERIOD : Sep.2010 to Sep.2011.
STUDY POPULATION : All children aged between 28 days to
12 yrs who presented with seizure
Satisfying the study criteria were included.
SAMPLE SIZE : 100
INCLUSION CRITERIA : All children aged between 28 days to
12 yrs who got admitted with documented
Convulsive episodes.
EXCLUSION CRITERIA : Convulsion with the history suggestive
Of acute antecedent events like trauma,
Drugs, toxins.
Associated with fever
Cerebral palsy.
44
METHOD
In this study, hundred children aged 28 days to 12 yrs with seizure,
admitted to the Pediatric Ward of Annal Gandhi memorial government
hospital, Trichy, between September 2010 to September 2011 were studied.
Among the study group 53 were boys and 47 were girls.
The Study group was divided into 5 subgroups
1. Infants (28 days to 1 year)
2. Toddlerhood (2 to 3 years)
3. Preschool (3 to 6 years)
4. School age (6 to 10 years)
5. Adolescence.
We excluded neonatal seizures and seizures with fever, because these
disorders are diagnostically and therapeutically different. We also excluded
patients presenting with seizures following acute antecedent events like drugs,
toxins and trauma. Cerebral palsy with seizure disorders also excluded from
study.
After getting informed consent from both patient and parents, historical
and clinical data are collected and entered in the proforma (annexure 2).
History included patients age, sex, time and place of seizures, duration
of seizures, type of seizures(generalized / focal and multifocal / myoclonus,
myoclonic seizures and infantile spasms), the presence of any predisposing
conditions (history of fever, diarrhea and dehydration, ear discharge,
45
exanthematous illnesses, cough with expectoration, and any skin infections)
and any antecedent events (history of drugs ingestion, trauma, and toxins).
Detailed antenatal, natal and postnatal history including the history suggestive
of perinatal asphyxia obtained from parents. Detailed developmental and
immunization history obtained from parents. History of pork ingestion and
history of contact with open case of TB were obtained.
Detailed general examination, head to foot examination to look for
markers of TB infection and neurocutaneous markers were done. Vital signs
were monitored including temperature and detailed neurological examination
done specifically to look for focal neurologic signs, and any other abnormal
findings. other systems were examined.
Neuroimaging was done after stabilization. Among the hundred
children, 93 patients had CT examination, 24 patients had MRI scanning. 15
children had both examination and 7 children had direct MRI. Findings were
documented in proforma.neuroimaging findings are categorized into 10 classes
which includes Normal study, Ring enhancing lesions, Neuro degenerative
disorders, Tumors, Cerebrovacular accident, Congenital structural defect,
Calcifications, Neuro cutaneous syndrome, Metabolic disorders, and others
categorized as Miscellaneous.
Statistical analyses were conducted using SPSS 17 software. The
pattern of seizure distribution and correlation between seizure pattern and
neuroimaging findings were analyzed.
RESULTS AND ANALYSIS
46
RESULTS AND ANALYSIS
All patients were subjected to neuroimaging study, preferably MRI
study. In non emergency settings, the imaging test of choice is the MRI. 93
patients had CT scan, 24 patients had MRI examination, 15 patients had both
scanning, 7 patients had direct MRI scanning.4patients was shown normal
findings in CT examination but MRI revealed imaging abnormalities. 2 patients
had some ill defined lesions, MRI showed normal finding. Many a times MRI
helped us to differentiate neurocysticercosis and tuberculomas. MRI study
clearly delineated metabolic, neurodegenerative, and neurocutaneous disorders.
In our study Primary generalized seizures accounted 49 %( 49/100),
focal and multifocal seizures accounted for about 46 %( 46/100) and myoclonic
variety accounted 5%(5/100).(Fig-1)
Of the primary generalized seizures, GTCS 95 % (45/47) are the most
common, followed by absence 2.5 % (1/47) and GTS 2.5 % (1/47). Of the focal
and multifocal, CPS 63 % (29/46), SPS and PSGS accounted each of 17%
(8/46), in myoclonic seizures 5% (5/100), myoclonic seizures accounted 4%
(4/100) and infantile spasms accounted 1% (1/100).(Fig-2).
47
SEIZURES DISTRIBUTION (n=100)
(Fig-1)
SEIZURES DISTRIBUTION (n=100)
(Fig-2)
48
Boys were 53%, girls were 47%
In age distribution, infants accounted 5% (95/100) of studied population.
Toddlerhood accounted 11% (11/100). Preschool children accounted 27%
(27/100), school age children accounted 37% (37/100). Adolescence accounted
for 20 % ( 20/100).( Fig-3)
Neuroimaging abnormalities were found in 53% ( 25/47) of generalized
seizures(Fig-5), but 97% (45/46) of focal and multifocal seizures had
neuroimaging abnormalities. Myoclonic seizures have shown 60% (3/5) of
neuroimaging abnormalitities.
Normal neuroimagings study was found in 29% (29/100) of
patients,(Fig-5)
Ring enhancing lesions are found 35% (35/100) (Fig-6). Of the ring
enhancing lesions. Tuberculomas are accounted 65% (23/35), were as
Neurocysticercosis accounted for 35% (12/100)(Fig-7). Age distribution in
REL shown as toddlerhood 2.9% (1/35), school age 25.9% (9/35) and
adolescence 22.9% (8/35) (Table-1) (Fig-8 & Fig-9). REL are seen in boys for
about 48% (17/35) and in girls 51% (18/35). REL are more common in parietal
region 60% (21/35), followed by frontal region in 20% (7/35), occipital in
8.6% (3/35), and temporal regions in 8.6% (3/35) and REL are seen in
multiple sites for 2.9% (1/35) (Table-2).
49
AGE DISTRIBUTION(n=100)
(Fig-1)
GTCS –NEUROIMAGING FINDINGS (n=47)
(Fig-4)
50
NEUROIMAGING FINDINGS(n=100)
(FIG-5)
NEUROIMAGING FINDINGS(n=100)
(FIG-6)
51
REL-DISTRIBUTION (n=35)
(Fig-7)
REL-TUBERCULOMA AGE DISTRIBUTION (N=23)
(Fig-8)
52
REL-NEUROCYSTICERCOSIS-AGE DISTRIBUTION(n=12)
(Fig-9)
CONGENITAL STRUCTURAL DEFECTS (n=7)
(Fig-10)
53
REL-AGE DISTRIBUTION(n=100)
(Table-1)
Frequency Percent Valid toddlerhood 1 2.9
Preschool 9 25.7 Schoolage 17 48.6 Adolescenc 8 22.9 Total 35 100.0
REL- REGIONAL DISTRIBUTION (n=29)
(Table-2)
Frequency Percent Frontal 2 6.9 Temporal 2 6.9 Parietal 18 62.1 Occipital 2 6.9 Total 29 100.0
Congenital structural defects constituted 7% (7/100) of imaging
findings (Fig-6). Of which Disorder of segmentation accounted 2% (2/100)
Schizencephaly 1% (1/100) and Carpus callosal agenesis 1% (1/100),
Cerebellar malformations (Dandy-walker malformation) accounted 1% (1/100),
Malformation of cortical development 2% (2/100) Lissencephaly 1% (1/100)
and Heterotopia 1% (1/100), Arachnoid cyst 1% (1/100) and Neuroglial cyst
1% (1/100) of neuroimaging findings(Fig-10).
Cerebrovascuar accident 8 % ( 8/100) and Tumors 4% (4/100) (PNET
1% (1/100), Craniopharyngioma 1% (1/100), Basal ganglia mass 1% (1/100),
Astrocytoma 1% (1/100)) accounted for 12% (12/100) of neuroimaging
54
findings (Fig-6). Calcifications accounted for about 5% (5/100) of findings in
neuroimaging.(Fig-6)
Neurodegerative disorders constituted for about 3% (3/100) of
neuroimaging findings Fig-6 Adrenoleukodystrophy-1% (1/100), Tay Sach’s
disease (neuroimaging abnormality correlated with history and clinical
examination) -1% (1/100) and Metachromatic leukodystrophy -1% ( 1/100)).
Neurocutaneous syndromes accounted for 2% (2/100) of neuroimaging
findings (Fig-6). Of the neurocutaneous disorders Tuberous sclerosis (tubers
was seen in ependymal surfaces of ventricles in contrast CT Brain) was seen in
1% (1/100) of neuroimaging findings and leptomeningeal angioma in occipital
region (Sturge-weber syndrome) was the imaging findings in 1% (1/100).
Diagnosis of Metaboic disorders made with metabolic workup along
with MRI imaging of brain. Phenylketonuria (urine metabolic screening for
metabolic screening-ferric chloride test was positive for phenylketonuria)
accounted 1% (1/100) of imaging findings. Wilson’s disease (laboratory report
shown decreased serum Copper levels) constituted 1% (1/100) of imaging’s.
Leigh’s syndrome (bilateral Symmetrical hyper intensities were seen in both
basal ganglia region). MRS was planned to see for lactate peaks. Patient
expired on third day due to Refractory seizures.
Other findings were included as Miscellaneous findings 4% (4/100),
(Fig-6) which includes Mesial temporal sclerosis 1% (1/100), Posterior
Reversible Encephalopathy Syndrome Following hypertensive encephalopathy
1% (1/100), Post viral Encephalomyelitis 1% (1/100) and Postictal edema 1%
(1/100).
NEURO IMAGINGS
NEURO IMAGINGS
BRAIN NORMAL STUDY IN COMPUTED TOMOGRAPHY
TUBERCULOMA BRAIN IN COMPUTED TOMORAPHY
PARANCHYMAL NEUROCYSTICERCOSIS IN COMPUTED TOMOGRAPHY
OPEN LIP SCHIZENCEPHALY IN MRI
DANDY – WALKER MALFORMATION IN MRI
LISSENCEPHALY IN COMPUTED TOMOGRAPHY
CARPUS CALLOSAL AGENESIS IN COMPUTED TOMOGRAPHY
HETEROTOPIA IN MRI
ARACHNOID CYST IN MRI
NEUROGLIAL CYST IN MRI
PNET (TUMOR) IN MRI
LEFT MCA INFARCT IN COMPUTED TOMOGRAPHY
CALCIFICATION IN COMPUTED TOMOGRAPHY
METACHROMATIC LEUKODYSTROPHY IN MRI
TUBEROUS SCLEROSIS IN COMPUTED TOMOGRAPHY
WILSON’S DISEASE (GIANT PANDA’S SIGN) IN MRI
LEPTOMENINGEAL ANGIOMA (SWS) IN COMPUTED TOMOGRAPHY
LEIGH’S SYNDROME IN MRI
MESIAL TEMPORAL SCLEROSIS IN MRI
POST VIRAL ENCEPHALO MYELITIS IN MRI
DISCUSSION
55
DISCUSSION
1. In our study, seizures are more common in school age children (37/100) and
then drops in teenage years, were as previous study (Camfield et al,)(2).
Stated that the incidence is high in Infancy and between 1-10 years of age,
the Incidence plateaus and then drops in teenage group. Seizures are more
common in school age children beyond infancy excluding fever related
epilepsies.
2. In our study, the most common seizures type is generalized seizures
accounted for 49% (49/100) followed by focal and multifocal 46% (46/100)
and myoclonic seizures 5% (5/100). Previous study stated that 48% had
generalized epilepsy syndromes and 45% had localization related epilepsy
(Eriksson et al)(3). Both studies are comparable to each other. Generalized
seizures are more common followed by localization related seizures.
3. In our study, of generalized seizures generalized tonic-clonic seizures
accounted for 95% (47/49) followed by absence 2% (1/47). Of focal and
multifocal seizures, complex partial seizures accounted for 63% (29/46) of
seizure type followed by partial seizures with generalized seizures 17%
(8/46). These data’s are comparable to previous studies (Hauser and
Kurland )(6) (Tapani Keranen, Matti Sillanpaa)(45). Of the primary
generalized seizures, generalized tonic clonic are the most common,
followed by absence. Of the focal and multi focal seizures, complex partial
56
seizures are more common followed by partial seizure with generalized
secondary.
4. In our study, Normal neuroimaging accounted 29% (29/100) and
neuroimaging abnormalities were found in 71% (71/100). Previous studies
(Fariba Khodapanahandeh and Homayon Hadizadeh), 2006(46), stated
that neuroimaging abnormalities seen in small population of patients. In our
study, we excluded the most common causes of seizures like acute CNS
infection, trauma, toxin and drug induced seizures. We also excluded febrile
convulsions and seizures caused by cerebral palsy. It may be the cause for
these differences.
5. In our study, Neuro imaging abnormalities were seen more with localization
related epilepsies 97% (45/46) than generalized seizures. In generalized
seizures Neuro imaging abnormalities were seen in 46% (22/47). Normal
imaging was shown in 54% (25/47) of generalized seizures. This study is
comparable to previous studies done by (Hirtz et al,)(51) (Fariba khodapanahandeh
and Homayon Hadizadeh)(46). Neuro imaging abnormalities are more
common with localization related epilepsy.
6. In our study, the most common Neuroimaging findings are Ring enhancing
lesions 35% (35/100), which is comparable to study done previously in
certain developing country like India (Export committee on pediatric
epilepsy, Indian academy of pediatrics)(44). Single small enhancing CT
Lesion brain is the most common neuro imaging abnormality in developing
countries.
57
7. Our study stated that Tuberculoma brain is the most common cause for
Ring enhancing lesion in children which accounted for 65% (23/35) of ring
enhancing lesions followed by neurocysticercosis which is accounted for
35% (12/35) of such lesions. Nelson text book of Pediatrics (52) stated as
Tuberculomas are account for up to 40% of brain tumor in some areas of
world. Tuberculomas are the most common neuro imaging findings in some
developing countries.
8. Both Tuberculomas and neurocysticercosis are seen mostly in parietal
region 60% (21/35), which is comparable to previous studies conducted in
India (Sachdev et al.,) (55) (Srinivas et al)(57) SSECTL brain are more
common in parietal region.
9. In our study, Ring enhancing lesions were common among preschool and
school age children, Tuberculomas were common among school age
children 56% (13/23), were as Neurocysticercosis are common among
preschool children 50% (6/12),Previous study stated that SSECT lesion are
common between 5-8 years (Sachdev et al.,)(55).. Our study is comparable
to previous study conducted in india. Ring enhancing lesions are common
among Pre school and School age children.
10. Tumors and Cerebro Vascular Disease accounted for about 12% (12/100) of
studied population in our study which is comparable to previous study
(Douglas R and Nordli )(53). Tumors and strokes constituted 10% of
neuroimaging findings among the seizure population.
58
11. In our study, Myoclonic seizures are associated with neuro degenerative
disorders and metabolic disorders. Previous studies stated that myoclonic
seizures are associated with mitochontrial, storage and progressive
disorders (DiMauro and Moraes)(50). Hence myoclonic seizures need
evaluation for neurodegenerative and metabolic disorders.
12. Other neuroimaging findings include Congenital structural defects 7%
(7/100), Calcification 5% (5/100), Neuro degenerative disorders 3%
(3/100), Metabolic disorders 3% (3/100), Miscellaneous conditions like
ADEM, MTS, Post ictal edema, Reversible posterior encephalopathy
syndrome. No much studies are available to compare these disorders.
SUMMARY AND
CONCLUSION
59
SUMMARY AND CONCLUSIONS
• Generalised seizures are the most common seizure and generalized
tonic-clonic seizures are the most common seizure in subclassification.
• Generalized seizures are mostly associated with normal neuroimaging
study
• Focal and multifocal seizures are mostly associated with neuroimaging
abnormalities.
• Children and adolescents presenting with myoclonic epilepsies, need an
evaluation for mitochondrial, storage, and other progressive disorders
like degenerative disorders.
• Single small solitary enhancing lesion brain are the most Common
neuroimaging findings in children in our population.
• Among SSECTL brain, Tuberculomas are most common followed by
Neurocysticercosis in our population.
RECOMMENDATIONS
60
RECOMMENTATIONS
• All children presenting with seizure require neuroimaging study and
electroencephalography with other specific investigations as needed.
• ‘Tuberculomas are most common neuroimaging finding in our population.
Hence strategies to be implemented to prevent tuberculous infection
among children.
ANNEXURES
61
MASTER SHEET (Annexure-1)
S. No
AGE SEX TOS NS REL REL-S REL-R NDD TUM CVA CSD CSD-C CAL NCS MET MISC
1 4 1 1 1 - - - - - - - - - - - -
2 4 2 5 - 1 1 3 - - - - - - - - - 3 5 2 1 1 - - - - - - - - - - - - 4 4 1 1 - - - - - - 1 - - - - - - 5 3 1 1 1 - - - - - - - - - - - - 6 4 1 8 - - - - 1 - - - - - - - - 7 5 1 1 - - - - - 1 - - - - - - - 8 4 1 1 1 - - - - - - - - - - - - 9 5 2 5 - 1 1 3 - - - - - - - - - 10 3 1 5 - - - - - - - 1 1 - - - - 11 3 1 4 - - - - - - 1 - - - - - - 12 3 1 5 - - - - - - - - - - - - 1 13 4 2 6 - - - - - - - - - - - - 2 14 4 1 1 1 - - - - - - - - - - - - 15 5 2 4 - - - - - - - - - 1 - - - 16 4 1 5 - 1 2 3 - - - - - - - - - 17 3 1 2 1 - - - - - - - - - - - - 18 4 2 1 1 - - - - - - - - - - - - 19 3 2 6 - 2 1 4 - - - - - - - - - 20 5 1 6 - 1 1 3 - - - - - - - - - 21 4 1 5 - 1 1 3 - - - - - - - - - 22 5 2 1 - - - - - - - - - - - 2 23 3 2 4 - 2 2 3 - - - - - - - - -
62
24 3 2 5 - 1 2 3 - - - - - - - - - 25 3 2 1 - - - - - - - 5 - - - - - 26 4 2 1 - - - - - 1 - - - - - - - 27 5 2 5 - 2 2 3 - - - - - - - - - 28 3 1 1 - 1 1 1 - - - - - - - - - 29 4 1 1 1 - - - - - - - - - - - - 30 5 2 1 1 - - - - - - - - - - - - 31 2 1 1 - - - - 2 - - - - - - - - 32 5 2 5 - 1 1 2 - - - - - - - - - 33 5 1 5 - 1 2 2 - - - - - - - - - 34 5 2 5 - 2 1 3 - - - - - - - - - 35 3 1 5 - 2 1 3 - - - - - - - - - 36 3 2 1 - - - - - - - 3 2 - - - - 37 4 1 1 - 1 1 1 - - - - - - - - - 38 2 1 1 1 - - - - - - - - - - - - 39 5 1 8 - - - - 3 - - - - - - - - 40 3 2 1 1 - - - - - - - - - - - - 41 3 2 6 - - - - - 1 - - - - - - - 42 4 1 7 - - - - - - 1 - - - - - - 43 4 1 5 - 1 1 3 - - - - - - - - - 44 3 2 1 - - - - - - 1 - - - - - - 45 4 2 5 - 2 1 1 - - - - - - - - - 46 4 1 1 - - - - - - 1 - - - - - - 47 4 2 6 - 1 1 3 - - - - - - - - - 48 5 2 1 - - - - - - - - - - - - 3 49 4 1 1 1 - - - - - - - - - - - - 50 4 1 5 - 1 1 3 - - - - - - - - - 51 5 1 5 - - - - - - - - - 1 - - - 52 4 2 5 - 1 1 3 - - - - - - - - -
63
53 2 2 8 1 - - - - - - - - - - - - 54 3 1 6 1 - - - - - - - - - - - - 55 3 2 5 - 2 1 1 - - - - - - - - - 56 5 1 4 - 1 1 1 - - - - - - - - - 57 3 2 1 - - - - - - - 4 - - - - 58 2 2 1 1 - - - - - - - - - - - - 59 2 1 1 1 - - - - - - - - - - - - 60 4 2 5 - 1 1 3 - - - - - - - - - 61 4 1 1 1 - - - - - - - - - - - - 62 4 2 4 - - - - - - - - - 1 - - - 63 2 2 1 - - - - - 1 - - - - - - - 64 4 1 1 1 - - - - - - - - - - - - 65 4 2 5 - 1 1 3 - - - - - - - - - 66 1 1 1 1 - - - - - - - - - - - - 67 4 1 5 - 2 1 3 - - - - - - - - - 68 4 2 1 1 - - - - - - - - - - - - 69 5 2 1 1 - - - - - - - - - - - - 70 2 1 8 - - - - - - - - - - - 1 - 71 2 2 6 - - - - - - - - - - 2 - - 72 5 1 1 - - - - - - - - - - 1 - - 73 3 1 1 1 - - - - - - - - - - - - 74 4 1 1 2 3 - - - - - - - - - - 75 2 2 4 - - - - - - 1 - - - - - - 76 3 2 6 - 1 2 1 - - - - - - - - - 77 1 1 1 - - - - - - - - - - - 3 - 78 4 2 1 - - - - - - - 1 2 - - - - 79 1 1 9 - - - - - - - 3 1 - - - - 80 4 2 5 - 1 1 3 - - - - - - - - - 81 3 1 1 1 - - - - - - - - - - - -
64
82 3 2 1 1 - - - - - - - - - - - - 83 3 1 5 - 2 1 3 - - - - - - - - - 84 4 1 1 1 - - - - - - - - - - - - 85 4 2 3 1 - - - - - - - - - - - - 86 5 1 5 - 1 2 3 - - - - - - - - - 87 4 1 5 - - - - - - - - - 1 - - - 88 2 2 1 - - - - - - - 2 1 - - - - 89 4 1 4 - 1 1 2 - - - - - - - - - 90 1 2 1 - - - - - - 1 - - - - - - 91 5 1 1 1 - - - - - - - - - - - - 92 4 2 5 - 1 1 3 - - - - - - - - - 93 3 1 4 - - - - - - - - - 1 - - - 94 2 1 1 - 1 2 1 - - - - - - - - - 95 3 2 1 - - - - - - - - - - - - 4 96 3 1 1 1 - - - - - - - - - - - - 97 1 1 5 - - - - - - 1 - - - - - - 98 4 2 5 - 2 1 4 - - - - - - - - - 99 5 2 1 1 - - - - - - - - - - - - 100 3 1 5 - 2 1 4 - - - - - - - - -
65
KEY TO MASTER CHART
S.No - Serial Number
AGE - 1-Infants
2-Toddlerhood (2-3 YR)
3-Preschool (3-6 YR)
4-School age (6-10 YR)
5-Early adolescence (11-12 YR)
SEX - 1-Boys; 2-Girls
TOS - Type of seizures
1-Generalised tonic clonic seizure
2-Generalised tonic seizure
3-Absence seizure
4-Simple partial seizure
5-Complex partial Seizure
6-Partial with secondary generalization
7-Multifocal Seizure
8-Myoclonic seizure
9-Infantile spasms
NS - Normal study
1-Normal study
REL - Ring enhancing lesions
1-Tuberculoma
2-Neurocysticercosis
66
REL-S - Ring enhancing lesions-side
1-Left
2-Right
3-Multiple
REL-R - Ring enhancing lesion-region
1-Frontal
2-Temporal
3-Parietal
4-Occipital
NDD - Neuro degenerative disorders
1-Adrenoleukodystrophy
2-Metachromaticleukodystrophy
3-Tay Sach’s disease
TUM - Tumors
CVA - Cerebrovacular accident
CSD - Congenital structural defect
1-Disorder of segmentation
2-Cerebellar malformation
3-Malformaton of cortical development
4-Arachnoid cyst
5-Neuroglial cyst
CSD-C - Congenital structural defect-Classification
1.1-Schizncephaly
1.2-Carpal callosal agenesis
2.1-Dandy-Walker Malformation
3.1-Lissencephaly
3.2-Heterotopia
67
CAL - Calcifications
NCS - Neuro cutaneous syndrome
1-Tuberous sclerosis
2-Sturge Weber Syndrome
MET - Metabolic disorders
1-Phenylketonuria
2-Wilson’s disease
3-Leigh’s syndrome
MISC - Miscellaneous
1-Mesial temporal sclerosis
2-Posterior reversible encephalopathy syndrome
3-Post viral encephalomyelitis
4-Postictal edema
68
PROFORMA (Annexure-2)
Name:
Age/Sex: Date of Admission:
IP No/OP No: Date of Discharge:
Informant:
Consanguinity:
Address:
CONVULSIONS
Date/Time:
Place:
No of episodes:
Duration:
Type of seizures
Generalized
Focal and Multifocal
Myoclonus,Myoclonic seizures, And infantile spasms
Nature of seizures
Tonic-Clonic/Clonic /Tonic/Atonic/Absence (typical/atypical)
Simple partial/Complex partial/Partial with secondary generalization
Myoclonic
Associated factors
Prodromes/Aura/Autonomic Phenomena/ALOC/Bladder and bowel
Incontinence/Frothing from mouth/Version/Automatisms
Seizures activation
69
Postictal deficit
Mode of arrest
Spontaneous/with medications
H/o Fever (Infections)
H/o Drugs/Trauma/Toxins
H/o Gross developmental delay
Previous similar episodes of seizure
Antenatal/Birth/Neonatal History
Family history/Contact History
EXAMINATION
General examination
Head to foot examination
Examination of Central Nervous System and Peripheral Nervous System
NEURO IMAGINGS
Cranial Ultra Sonograrhy
Computed Tomography
Magnetic Resonance Imaging
Other Imagings
Magnetic Resonance Spectroscopy, Diffusion-Imaging, Perfusion
Mri, Susceptibily -Weighted Imaging, Functional Mri, Magnetic Source
Imaging.
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